Leverndale Hospital. Electroconvulsive Therapy (ECT) Service. Guidelines and Protocols Roles and Responsibilities. Version 3 (January 2012) Page 1

Transcription

1 Leverndale Hospital Electroconvulsive Therapy (ECT) Service Guidelines and Protocols Roles and Responsibilities Version 3 (January 2012) Page 1

2 Contents Page 4 Page 5 Page 6 Page 7 Page 7 Page 8 Page 12 Page 13 Page 14 Page 15 Page 17 Page 21 Page 22 Page 23 Page 24 Aims & objectives The use of ECT in contemporary practice Indications for ECT Contraindications to ECT Adverse events and side-effects Consent and ECT Special situations Preparing for treatment and other considerations Physical assessment prior to ECT Psychotropic drug treatment and ECT Some principles of ECT administration Dose titration and treatment protocols Bilateral ECT treatment protocol Unilateral ECT treatment protocol Stimulus dosing schedule Version 3 (January 2012) Page 2

3 Page 25 Page 26 Page 27 Page 27 Page 28 Page 28 Page 34 Page 35 Page 35 Page 36 Page 37 Page 38 Page 41 Page 44 Page 45 Practical administration of ECT Prescribing ECT Preparation of patient Attaching EEG monitoring equipment Anaesthesia Administration of stimulus/seizure monitoring Monitoring response to treatment Treatment course, mode of improvement and when to stop Efficacy, preventing relapse and maintenance therapy NICE guidelines Roles and Responsibilities The ECT team The referring team ECT service contact details Useful information Version 3 (January 2012) Page 3

4 Aims and Objectives The following objectives will ensure that ECT is delivered safely and effectively. Our objectives are: Ensure all new trainee doctors attend the induction programme for ECT. Ensure that all doctors are familiar with their role and responsibilities within ECT practices. Ensure a consultant trains junior doctors in the clinical application of ECT. Ensure all referring consultants are familiar with their role and responsibilities within ECT practices. Ensure nursing staff are familiar with their roles and responsibilities within ECT practices. Junior doctor ECT training programme The training programme will consist of a theoretical presentation at new trainee induction, accompanied by distribution of the handbook and/or other literature associated with ECT e.g. DVD given to trainees at induction. Thereafter doctors who are planning to administer ECT will undergo supervised practical training which will include observation of an ECT session followed by at least three supervised sessions administering ECT. A note of the trainees giving ECT along with a record of their training will be kept in the ECT Suite. Version 3 (January 2012) Page 4

5 The use of Electro-Convulsive Therapy (ECT) in contemporary practice Version 3 (January 2012) Page 5

6 This handbook replaces previous guidance on the use of Electroconvulsive Therapy (ECT) in Leverndale hospital. It is not intended as a definitive guide to the principles and practice of ECT. Medical staff are encouraged to consult authoritative publications. Indications for ECT ECT is a treatment that has been used in the treatment of depressive illness, mania, catatonia and occasionally schizophrenia. Depression The main use of electroconvulsive therapy is in depressive illness. ECT is most commonly used when a patient has failed to respond to antidepressant medication. Factors predicting a good outcome from ECT include psychotic features, psychomotor retardation, previous good response to ECT and a strong collection of biological depressive features. In the most severely depressed people with psychotic features, stupor or major suicide risk, ECT may be considered as a first choice treatment. Mania ECT is effective in acute mania, although neuroleptics, lithium and anticonvulsants remain the main choice of treatment. Schizophrenia ECT is sometimes used in schizophrenia where prominent depressive symptoms are present. Acute positive schizophrenic symptoms do respond to ECT but drug treatments remain the main stay of treatment. ECT is unlikely to be effective for negative schizophrenic symptoms. Other Conditions ECT has been described as being effective in catatonia, neuroleptic malignant syndrome and delirious states. It may also have some effects on Parkinsonian symptoms. The National Institute for Clinical Excellence (NICE) reviewed the use of ECT and published their recommendations in Guidance in the use of Electroconvulsive Therapy (2003). NICE recommend that ECT is used only to achieve rapid and short term improvement of severe symptoms after an adequate trial of other treatment options have proven ineffective and/or when the condition is considered to be potentially life-threatening, in individuals with severe depressive illness, catatonia, or prolonged severe manic episode. Version 3 (January 2012) Page 6

7 Contra-indications to ECT There are no absolute contra-indications to ECT. In all cases, a balance needs to be made between risk of the procedure and benefits expected. ECT is particularly hazardous in people with raised intracranial pressure and should be used with great caution within three months of heart attack or stroke. Other relative contra-indications include anaesthetic risks such as metabolic abnormalities, heart disease and lung disease. ECT can be used in people with epilepsy that is well controlled. Caution must be observed with people who have significant symptomatic gastro-esophageal reflux disease. Adverse Events and side-effects Mortality Recent evidence from the Scottish National Audit of ECT suggests that the mortality rate is greater than the often quoted 2-3 deaths per 100,000 treatments. ECT is regarded as having no greater risk than any other procedure involving a short-acting general anaesthetic, but mortality may be higher because of attempts to treat very ill and very frail people where the procedure is known to carry a risk, but where the risk of not treating is judged much greater. Cognitive impairment Memory disorder commonly occurs during a course of ECT. ECT may cause short or long term memory impairment of past events (retrograde amnesia) and/or current events (anterograde amnesia). As this type of cognitive impairment is a feature of many mental health problems, it may sometimes be difficult to differentiate the effects of ECT from those associated with the condition itself. There are also differences in individuals perception of memory loss secondary to ECT. However, this should not detract from the fact that a number of individuals find their memory loss extremely damaging and, for them this may negate any benefit from ECT. There is no evidence that ECT causes prolonged impairment of new learning, however, there are reports that some people experience long term retrograde memory impairment usually associated with biographical aspects of their life. Cognitive impairment is greater in individuals who have had electrodes applied bilaterally as opposed to unilateral placement and unilateral placement to the dominant hemisphere causes more impairment than that to the non-dominant hemisphere. Risk of cognitive impairment can therefore be reduced by administering unilateral ECT to the non-dominant hemisphere. A reduction in the risk of cognitive impairment is however mirrored by a reduction in efficacy. Version 3 (January 2012) Page 7

8 There is some limited evidence from Randomized Controlled Trials to suggest that the effects on cognitive function may not last beyond six months, but this has been inadequately researched. There is also evidence to suggest that the impairment of cognitive function associated with ECT differs between individuals and is linked to the dose administered, although the relationship with the seizure threshold has not been adequately defined. There is no evidence to suggest that the effect of ECT and cognitive function differs between diagnoses. Other side-effects ECT administration affects the central nervous system and causes changes in cardiovascular dynamics. This dictates the need for special caution in those individuals who are at increased risk of a cardiovascular event. There are also the immediate potential complications such as status epilepticus; laryngospasm and peripheral nerve palsy which overall have an estimated incidence of 1 per 1,300 to 1,400 treatments. It is very common to have a headache after ECT. Jaw and neck pain are also reported. Rarely, aspiration of stomach contents occurs. In patients with or who are susceptible to bipolar disorder, a manic episode can occur when ECT is being used for depressive disorder. Consent to ECT Both good practice and lawful practice require close attention to the issue of consent. Informal Patients No informal patient can be treated for any mental disorder in the absence of consent. This is generally taken to mean that the patient understands what the treatment entails, its purpose and likely effects, both beneficial and adverse. The patient should also understand what any other treatment choices might be and the likely effects, both beneficial and adverse of these. They should be aware of the consequences if they do not have the treatment. The patient can then consent to the treatment in writing on the basis of understanding the explanation given. The degree of explanation given and understanding required is for the individual clinician to judge. Following explanation of ECT, the patient should be aware that the treatment involves stimulation of the brain by electricity under anaesthetic to produce a modified seizure, and that this has been shown, through changes in brain chemistry, to improve symptoms of mental illness such as severe depression. Clinicians are strongly advised to give the patient written information which can be obtained from the ECT suite. Version 3 (January 2012) Page 8

9 The patient should be advised that although consent has been given at the start of the course, that consent may later be withdrawn. Consent must be considered in relation to each individual ECT treatment, though separate documentation is not necessary for each treatment. If the doctor in charge of the patient s treatment is satisfied that real consent can be and has been given, the patient should be asked to sign a standard consent form, and the doctor should also sign. The form produces evidence that consent has been sought but not of the validity of that consent. It is therefore advisable to make a note in the case record of the interview at which consent was obtained. Consent should be up to a limited and stated number of treatments given within a stated frequency. If there is a gap of more than two weeks between consent and the start of treatment, fresh consent procedures should be followed and if there is a break of more than two weeks in the course of treatments the subsequent treatments should be regarded as a fresh course for which new consent procedures are required. Next of kin cannot give consent on the patient s behalf. In a situation where an informal patient seems to require ECT and is unable to give valid informed consent, there are two possible mechanisms for treating with ECT. A patient, who is incapable of consenting but not actively resisting or opposing treatment, can be treated under the provisions of the Adults with Incapacity (Scotland) Act This requires a Consultant to certify the patient as incapable under Section 47 of that Act and obtain an independent opinion under Section 48, obtained via the Mental Welfare Commission. The patient could be treated under the Mental Health (Care and Treatment) (Scotland) Act Detained patients The procedure for the administration of ECT to detained patients is outlined under Sections 238 and 239 of the Mental Health (Care and Treatment) (Scotland) Act The patient must either give valid and informed consent or must receive a second opinion from an independent doctor, appointed by the Mental Welfare Commission. Where a patient gives consent, this must be recorded by the Responsible Medical Officer on Form T2, Section 238. If the patient is unable to give consent, the Responsible Medical Officer must detail the treatment plan, stating the type of treatment to be used and, for ECT, the maximum Version 3 (January 2012) Page 9

10 number of treatments expected. The Mental Welfare Commission will then be contacted. The second opinion doctor will, if he agrees with the treatment plan, certify this on Form T3, Section 239. Under the Mental Health (Care and Treatment) (Scotland) Act 2003, a detained patient can make a competent refusal of treatment. In this instance the patient understands the nature, purpose and likely effects of the treatment and understands the implications of not consenting to it, but still refuses. This patient can only be given ECT against their will, if the very strict criteria of Section 243 (3) are met. This would indicate the purpose of giving ECT would be to save the patient s life, prevent serious deterioration in the patient s condition, alleviate serious suffering on the part of the patient and/or prevent the patient from behaving violently or being a danger to himself or others. In urgent cases it is possible, and sometimes necessary, to administer ECT before obtaining a second opinion. In order to do this, the patient will require to be detained on a Short Term Detention Certificate or a Compulsory Treatment Order, and treatment will be specified under Section 243 of the Mental Health Act. In all instances where ECT is given on an urgent basis, the Mental Welfare Commission should be informed in writing within seven days (Form T4). The Mental Welfare Commission advises that an opinion be sought from a local consultant and that the situation be discussed fully with the patient s relatives before going ahead with ECT in this case. In all cases, ECT staff must be clear as to the Legal position. All relevant legal documentation must be available to the ECT staff to allow treatment to progress. Version 3 (January 2012) Page 10

11 Mental Health (Care and Treatment) (Scotland) Act 2003 Legal status & consent (ECT) Status Consent Comments Informal Informed AWI S47/48 AWI Urgent T5 Adults over 16 years Under 16 years Emergency detention certificate (S36) Lasts up to 72hrs. Informed T4 Accepted but review if detained further Urgent (Doubtful situation discuss with MWC before proceeding) Short term detention certificate (S44) Lasts up to 28 days T2 * T3A T3B T4 Capable of consenting not Incapable not resisting or objecting Incapable resisting or objecting Urgent Compulsory treatment order (S57) Lasts up to 6 months, extended for further 6 months, then annually T2* T3A T3B T4 Capable of consenting not refusing treatment Incapable not resisting or objecting Incapable resisting or objecting Urgent Mentally disordered offender procedures T2 * T3A T3B T4 Capable of consenting not refusing treatment Incapable not resisting or objecting Incapable resisting or objecting Urgent * MWC consent documents and also separate sheet accompanying T2 which patient signs required Version 3 (January 2012) Page 11

12 Special situations Elderly Old age is no specific contra-indication to ECT and in some cases may be safer than the use of psychotropic drugs. However, the recent NICE guidelines suggest that the risk associated with ECT may be enhanced in older people and that clinicians should exercise particular caution when considering ECT in this group. Very young patients The recent NICE guidelines suggest that the risk associated with ECT may be enhanced in children and young people, and that clinicians should exercise caution when considering ECT in this treatment group. Outpatient ECT It is possible to prescribe ECT for outpatients. However, all outpatients who receive general anaesthesia must be given very strict instructions regarding care after the procedure. They must be given clear instructions regarding fasting and must not present significant anaesthetic risks. They must not drive during the course of ECT and seek DVLA advice before resuming driving. After each treatment, the patient must be supervised by a responsible adult for 24 hours. Information sheets for patients are available in the ECT Suite. If the ECT staff are not satisfied that these arrangements are in place, ECT will not be given. It may be necessary to return the patient to the Sector Admission Ward following treatment if there are complications requiring overnight observation, or if arrangements for care of that person following ECT fall through. Version 3 (January 2012) Page 12

13 Preparing for treatment and other considerations Version 3 (January 2012) Page 13

14 Physical assessment prior to ECT A proper physical assessment is required before ECT will be prescribed. This includes: A systemic enquiry of symptoms with particular emphasis on cardiovascular and respiratory symptoms, and symptoms suggestive of gastro-oesophageal reflux disease. Note should also be made if the patient has had a recent myocardial infarct or cerebrovascular event, has severe respiratory disease, diabetes or is on medications such as warfarin, clopidogrel or MAOIs. If the patient is too mentally unwell to give such a history, attempts should be made to ascertain relevant information from next of kin or General Practitioner. Any previous anaesthesia, ECT or complications arising must be noted. A full physical examination must be performed, again with particular emphasis on anaesthetic risk factors; cardiac diseases such as cardiac failure, valvular disease, recent or unstable arrhythmia or uncontrolled hypertension. Significant infection, obesity, cachexia, poor dentition and arthritis of jaw and neck should also be noted. Blood should be taken for full blood count, Us & Es if the patient is on lithium, diuretics, vasoactive or cardiac drugs, or if he/she is diabetic or has renal disease. LFTs if the patient is cachectic, there is a history of alcohol or drug abuse or recent self poisoning, INR if the patient is taking warfarin, glucose if the patient is diabetic or urinalysis is positive for sugar, TFTs if on thyroxine, and digoxin or lithium levels were appropriate. A recent ECG must be available for inspection, if the patient has known cardiac, respiratory, or renal disease, an irregular pulse or heart murmur, hypertension, diabetics over 40 and everyone over 50. (Local protocol states all patient s should have an ECG). If there is a suspected chest infection, cardiac failure, cardiomegaly, pulmonary embolism or trauma, for example, fracture, a chest X-ray should be performed and the results made available. The Clinical Team is strongly advised to contact the Department of Anaesthesia at the Victoria Infirmary ( ). The consultant anaesthetists providing anaesthesia for ECT are very happy to see people for whom ECT is being considered in advance of treatment. This should occur in the majority of cases. However, where the situation is judged to be urgent, discussion with the responsible anaesthetist should take place on the telephone prior to treatment. If there are conditions which may increase the risk of ECT, discussion with the anaesthetist is essential. Version 3 (January 2012) Page 14

15 All medication should be recorded on the ECT prescription form and changes notified to the ECT staff. In particular, any medication which might alter the likelihood of a seizure taking place must be identified. Psychotropic drug treatment during and after ECT Benzodiazepine drugs Recommendations: Wherever clinically possible, the concomitant prescription of benzodiazepine drugs should be avoided during a course of ECT. If a hypnotic drug were clinically indicated at night, then it would be good practice to consider the use of a non-benzodiazepine drug. Long-established benzodiazepine drug use should not be stopped suddenly just a few days before a course of ECT because there is the risk of a dramatic lowering of seizure threshold. If the dose cannot be gradually reduced and stopped before ECT, it may be better to continue the drug during ECT, perhaps in reduced dosage. If a patient is taking as required benzodiazepines, it would be helpful if they were not given a long acting benzodiazepine from the afternoon prior to their ECT session, and in the case of short acting benzodiazepines, from 10p.m. on the evening before ECT. Antidepressant drugs Recommendations: An antidepressant drug should not be abruptly discontinued before ECT, particularly one with a short half life or one of the SSRI s Monoamine oxidase inhibitors do not need to be discontinued before ECT, but the anaesthetist should be informed in advance. It is probably better to prescribe an effective antidepressant drug at least before the end of a course of treatment, if only to provide adequate early prophylaxis. In elderly patients, or patients with pre-existing cardiac disease, potential cardio toxicity should influence the choice of drug. In-patients pre-medicated with an SSRI, it would be prudent to start with a low electrical dose (25-50 mc) at the first treatment. Version 3 (January 2012) Page 15

16 Lithium Recommendations: The co-administration of the lithium ion is not a contra-indication to ECT. Preliminary evidence suggests that the early introduction of the lithium ion reduces the likelihood of early relapse of depressive illness after ECT. The co-administration of the lithium ion may be one risk factor among several for adverse effects such as prolonged cerebral seizure activity. It may be prudent to start with a low electrical dose (25-50 mc) at the first treatment. Anti-epileptic drugs Recommendations: If used to treat epilepsy, the prescription of anti-epileptic drug should continue throughout the course of ECT. If used as a mood stabiliser, no evidence-based recommendation can be made; on balance, it may be better to continue prescription during the course of ECT. Anti-epileptic drugs may raise the seizure threshold, shorten seizure duration and modify the convulsion; ECT dosing schedules will therefore have to take account of the co-administration of anti-epileptic drugs. If the induction of seizures becomes problematic during the course of ECT, the prescribed dose may need to be reduced. Anti-psychotic drugs Recommendations: A small dose of sedative anti-psychotic drug may be preferred to a benzodiazepine drug if a hypnotic drug is indicated. The manufacturer of clozapine suggests that the drug be withheld for 12 hours before any general anaesthetic. Clozapine may lower the seizure threshold, and it may be prudent to start with a low electrical dose (25-50 mc) at the first treatment. Version 3 (January 2012) Page 16

17 Caffeine Recommendations: The co-administration of caffeine is unlikely to augment the therapeutic effects of ECT. Some principles of ECT administration Electric stimulus The goal of the treating physician is to deliver an electrical stimulus large enough to induce an adequate seizure while minimising the risk of significant side effects. The electrical stimulus can be characterised by the primary variables: current, voltage and time. In a physical sense, current is the number of electrons per second flowing through a circuit. In this case, the circuit is the: ECT machine, stimulus cables, stimulus electrodes, and The patient. Similarly, voltage is the: force that drives the flow of electrons during the stimulus, Push of the system. Impedance is: A measure of the obstacle to the current flow. The level of resistance to be overcome. In ECT, the terms impedance and resistance can be used interchangeably. The greater the resistance (or impedance), the greater the push (or voltage) required for the fixed flow of electrons. Conversely, the lower the impedance, less push or voltage is required to move a fixed current. This relationship is called Ohm s Law. Version 3 (January 2012) Page 17

18 Voltage Current = Resistance Impedance The electrical impedance during the passage of the stimulus current is a very important measure. It can differ substantially between patients and it can vary from treatment to treatment in the same patient (Sachem 1991, 1994; Coffey et al. 1995). The primary source of impedance is the scalp tissue that underlies the stimulus electrodes. Because the skull is associated with extremely high intrinsic impedance, most of the electrical stimulus current is shunted across the scalp tissue between the electrodes without ever passing through the brain. As a result, only a small fraction of the stimulus current actually enters the brain unless a low impedance pathway to the brain exists (e.g. a skull defect). For this reason, stimulus electrodes should never be placed over or adjacent to such a defect. Any scalp impedance which is too low is associated with an increased effectiveness in producing a seizure. This can occur when the ECT electrodes are placed too close together or when a conducting medium, e.g.: sweat saline or electrode gel forms a low impedance pathway (short circuit) between the electrodes. More commonly, it is possible for the impedance to be too high. This can occur when the stimulus electrodes are in poor contact with the skin, causing the current to flow through a smaller area. This situation makes it less likely that an effective stimulus will be delivered and also raises the theoretical risk of a skin burn (although this would be extremely rare with present devices). The most common cause of very high static impedance is failure to connect the stimulus cable to the stimulus electrodes. The second most frequent cause is inadequate coupling of the stimulus electrodes to the scalp, caused by: insufficient preparation of the scalp; insufficient use of the electrode gel (particularly when hair is in the way), or Version 3 (January 2012) Page 18

19 Too little pressure in the application of the stimulus electrodes to the scalp. Factors which can affect seizure threshold include Age Patients who are older have higher seizure threshold. Sex Male patients have higher seizure threshold (especially if bald). Medication Benzodiazepines and anticonvulsants raise seizure threshold. Some antidepressants lower seizure threshold. SSRI s and Venlafaxine have been reported to be associated with prolonged seizures. Hydration Significant dehydration and high urea raises the seizure threshold. Anaesthetic High doses of barbiturate anaesthetics raise the seizure threshold. Propofol is also associated with short seizures. CO2 Saturation Low levels of CO2, e.g. by hyperventilation, lower the seizure threshold. Caffeine Lowers seizure threshold. Intravenous caffeine prior to ECT can help to prolong seizures Seizure adequacy For many years, an ECT treatment was considered therapeutically adequate if the seizure was generalised and of a certain duration (Abrams 1997; American Psychiatric Association 1990; Ottosson 1960). The precise minimum duration of the seizure required for optimal therapeutic effect has never been established, and data supporting criteria for adequate duration are not compelling, in terms of the duration of either an individual seizure or cumulative seizure duration over the entire treatment course. For this reason, the determination of treatment adequacy has been based on clinical outcome rather than on the number of seconds of seizure activity. Version 3 (January 2012) Page 19

20 Stimulus intensity Recent evidence suggests that the greater the ECT stimulus intensity with respect to seizure threshold (i.e. the more suprathreshold the stimulus), the more effective the treatments and the speedier the recovery (Sackeim et al. 1993). However, it is also known that higher stimulus intensity is directly related to an increase in cognitive side effects. Thus the logical solution would be to deliver a stimulus that is moderately suprathreshold. Unfortunately, this solution is complex, for several reasons: Seizure threshold varies greatly from person to person and also from treatment to treatment, increasing variability over the treatment course (Sackeim et al. 1991). A number of factors influence an individual s seizure threshold, including age, gender, stimulus electrode placement, anaesthetic agents, psychotropic medications, and the number and recency of previous ECT treatments. We do not yet know how much above seizure threshold the stimulus needs to be in order to be considered moderate, although this is usually estimated to be 50% - 200% (or equivalent to one-and-one-half to three times) above the individual s seizure threshold. The stimulus dosing strategies that follow represent attempts to manage this problem. Version 3 (January 2012) Page 20

21 Dose titration and treatment protocols Version 3 (January 2012) Page 21

22 Bilateral ECT treatment protocol 1. Measure seizure threshold (ST) in mill coulombs (mc) Set machine at level 2 (around 50mC) for adults, both sexes (see chart for details of dose). Increase one level at a time until a seizure is produced (ST is therefore below this dose). Give a maximum of three* stimulations on any one ECT day. If no seizure, check your procedure and begin at level 4 next treatment For young people start at level 1 2. First full treatment session (note, this will usually be on the next ECT day) Set machine at a level which represents ST %, (this will usually be + 1 level). Position ECT electrodes over fronto-temporal areas bilaterally (see diagram). Follow the instructions for use of the ECT machine. Accept as satisfactory if a fully generalised tonic-clonic seizure is produced. Record the length of seizure for reference. 3. Stimulus dosing for subsequent ECT Increase dose by one level if no clinical improvement after four ECT treatments. Consider increase dose by one level if seizure shortens progressively to 50% original. Decrease dose by one level if cognitive side-effects are troublesome. 4. Termination of prolonged seizures Seizures lasting more than 120 seconds on EEG should be terminated. Help prepare midazolam, diazemuls or anaesthetic agent for the anaesthetist at 90 seconds. * If no seizure was obtained at levels 2 or 3, consider an increase to level 5 (approximately 175mc) for clinical efficiency. Version 3 (January 2012) Page 22

23 Unilateral ECT treatment protocol 1. Measure seizure threshold (ST) in mill coulombs (mc) Set machine at level indicated on seizure dosing schedule (see chart for details of dose). Increase one level at a time until a seizure is produced (ST is therefore below this dose). Give a maximum of three** stimulations on any one ECT day. If no seizure, check your procedure and begin at level 4 next treatment. 2. First treatment session (this will usually be on the next ECT day). Set machine at a level which represents 5-8 x seizure threshold (mc), see chart. Position ECT electrodes over right temple and right parietal-occipital areas. Follow the instructions for use of the ECT machine. Accept as satisfactory if a fully generalised tonic-clonic seizure is produced. Record length of the seizure for reference. 3. Stimulus dosing for subsequent ECT Increase dose by one level if no clinical improvement after four ECT treatments. Increase dose by one level if seizure length shortens progressively by 50%. Decrease by half a level if cognitive side-effects are troublesome 4. Termination of prolonged seizures Seizures lasting more than 120 seconds on EEG should be terminated. Prepare midazolam, diazemuls or anaesthetic agent for the anaesthetist at 90 seconds. ** If no seizure was obtained at levels 2 and 3, consider an increase to level 7 (approx 375 mc) for clinical efficacy. Version 3 (January 2012) Page 23

24 Stimulus dosing schedule for Thymatron system IV Suggested starting points Level % mc Female unilateral Person aged< Female bilateral Male bilateral Male unilateral Version 3 (January 2012) Page 24

25 Practical administration of ECT Version 3 (January 2012) Page 25

26 Prescribing ECT ECT machine The ECT Machine in use at Leverndale Hospital at present is the Thymatron System IV. The aim of administration of ECT is to produce a well modified, generalised, tonic-clonic seizure. Treatment can be administered in one of two ways; Bilateral ECT In this situation, electrode placement is bi-temporal. The correct placement of each electrode is 4 cms above midpoint between the outer angle of the eye and the external auditory meatus. Usually, this is above the hairline at the temple. Unilateral ECT In this situation, ECT is given to the non dominant hemisphere of the brain. For most people, this will be the right hemisphere. People who are left handed may be difficult to assess for dominance. It is important to find the preferred handedness for sports, preferred foot for kicking, preferred eye and make a judgment as to which hemisphere is more likely to be dominant. Electrode placement is as follows: the 1 st electrode is on the temple as described above. The second electrode should be 18 cms from this, close to the vertex. Generally this is only just on the same side of the head. Factors determining unilateral vs. bilateral electrode placement Research would indicate that bilateral ECT is more effective than unilateral treatment and treatments given at higher multiples above seizure threshold are more effective. On the other hand, cognitive side effects are greatest with bilateral ECT at levels significantly above seizure threshold. Unilateral ECT to the dominant hemisphere causes more cognitive side effects than unilateral ECT to the non-dominant hemisphere. There is some suggestion that, even at high doses, the cognitive side effects of non-dominant unilateral ECT are negligible. The results of a systematic review carried out by the UK ECT Review Group may help to inform choice of which type of ECT to use in the first instance. This would suggest that bilateral placement is preferred when speed and/or completeness of recovery have priority, and that unilateral placement is preferred when minimising cognitive adverse effects is the priority. No simple didactic statement can be made about the electrode placement of choice in all indications for ECT. The final selection of electrode placement ought to be a balance of the estimated risks and benefits for the patient at a particular point in the illness, and informed, where possible, by the views of the patient. Version 3 (January 2012) Page 26

27 Dose titration and seizure threshold - see protocols Preparation of the patient The patient should be fasted from the previous midnight. Ordinarily routine medications should be taken before ECT. This is particularly important for cardiac drugs, antihypertensive medication and treatments to reduce gastric acid. Diabetic patients on hypo-glycaemics should not receive these treatments prior to ECT because of fasting. Patients on as required medication with benzodiazepines should not receive these drugs before ECT. Short acting drugs, such as lorazepam or temazepam, should not be administered in the 12 hours prior to ECT. Long acting drugs such as diazepam and nitrazepam should not be administered in the 24 hours prior to ECT. The patient should be accompanied to the ECT Suite by a familiar nurse who will bring the patient s case notes and prescription record. Outpatients will travel with a responsible adult or have an escorting nurse from the appropriate Community Mental Health Team. The patient will be asked to visit the toilet to empty bladder and bowel if necessary prior to treatment, and vital signs, including respirations, pulse, blood pressure and temperature will be checked. False teeth and hairpins will be removed prior to treatment. The patient will be made comfortable on a trolley in the preparation area and wheeled through to the treatment area. The anaesthetist will be shown the patient s treatment record and results of any relevant investigations. If there are any particular concerns these should be discussed with the anaesthetist prior to ECT. Attachment of EEG monitoring equipment On entering the treatment area, the patient should be greeted by the Staff. The Nurse Coordinator will explain that during treatment, the electrical activity in the patient s brain will be monitored closely. In order to do this, electrodes will be applied to the patient s forehead (one above the lateral aspect of each eyebrow, one behind each ear (mastoid processes), and one on the clavicle. It should be explained that this is not treatment but will enable staff to monitor brain activity. It is strongly recommended that recording of brain activity begins as soon as the electrodes are attached in order to get the best possible baseline EEG measurement. Version 3 (January 2012) Page 27

28 Once electrodes are applied, press the front panel Impedance Test button and observe the static impedance display. When administering ECT the aim is to have impedance greater than 100 but less than When the Impedance Test button is pressed and held, the word TESTING will briefly appear in the 8 digit L.E.D. Then a number ranging from 0 to > 3000 ohms, representing the static impedance will appear. When the Impedance Test button is released, the number is replaced by the message BASELINE. The BASELINE message indicates that baseline EEG collection is in progress. When baseline EEG collection has been accomplished, the word READY will appear in the L.E.D. It normally takes around 6 10 seconds for READY to appear. Anaesthesia The patient will be anaesthetised with a short acting general anaesthetic. It is the practice of the Leverndale hospital ECT service, at the moment, to use Propofol; Etomidate is used as an alternative. The dose will be decided by the anaesthetist. In addition to the anaesthetic, Suxamethonium is administered as a muscle relaxant. On subsequent treatments, the dose of Suxamethonium is adjusted to ensure that some visible seizure activity can be observed, but that the patient is sufficiently relaxed to prevent injury from risk of violent seizures. During the entire procedure, EEG, pulse rate, oxygen saturation, ECG, blood pressure and CO2 output are monitored. Administration of electrical stimulus and seizure monitoring The doctor administering ECT must ensure that the prescription for ECT is clear. Once the patient is anaesthetised, the areas where treatment is to be applied are appropriately cleaned with a saline moistened swab and patted dry. The electrical stimulus can then be administered, using either traditional electrodes or Thymapad stimulus electrodes. If the latter are used, it may be better to apply these before the patient is anaesthetised. The doctor should follow the instructions in the prescription for electrode placement and electrical dosage. Using the per cent energy dial on the front of the machine, choose the desired percentage energy setting. A one second display then appears indicating the charge (mc) that corresponds to the per cent energy setting, followed by a return to the per cent energy number. Once the dose has been selected, press and hold the TREAT button down until the treatment light comes on and then goes off again. Whilst the TREAT button is held down, the following events will occur sequentially Version 3 (January 2012) Page 28

29 A 1-second continuous tone warning signal comes on, during which no current is delivered. If the impedance is greater than 3000, the warning tone is extended to 3 seconds. If the TREAT button is still pressed, the treatment will be delivered. The TREAT button lights up and an intermittent buzzing tone sounds whilst the current is being delivered. The TREAT button light and buzzing tone both turn off when the treatment stimulus ends. The TREAT button can then be released. Note: It is important to continue pressing the treatment button until the light goes off and the buzzing tone stops. Releasing the button early terminates the stimulus and delivers a smaller charge than intended. However, continuing to press the TREAT button after the stimulus ends will not deliver any additional stimulation. The audible EEG seizure monitor is activated unless the volume is turned off and the fourchannel printer automatically starts to provide a paper recording. If the printer is already running when the treatment stimulus is delivered, the printer will stop and automatically resume when the stimulus current ends. During this time the doctor will observe both the patient and the EEG monitor. When he or she believes that the seizure is complete, the Start-Stop button should be pressed. This generates the end of treatment report. The final decision on whether or not a seizure is completed is that of the doctor. The computer derived end point and seizure duration measures, including the ictal line seizure indicator, are derived solely by calculation and they are provided to aid, not replace, the doctor s judgment. It is possible for seizure activity to continue in the brain after any or all of the computer reports indicate seizure termination. It is also possible for artifacts to be interpreted by the computer programmes as seizure activity. The doctor should record the outcome of treatment on the ECT record sheet. Any problems or complications which arise during the course of ECT must be noted on the ECT treatment record form, documented in the patient s case-notes and communicated verbally to the patient s own clinical team. Procedure for administration of ECT Preparation Explain procedure to patient. Confirm patient identity with ECT nurse and anaesthetic staff. Version 3 (January 2012) Page 29

30 Check consent, prescription (laterality and dose). ECT machine should be switched on. Degrease scalp for EEG and electrode placement. Apply EEG electrodes (above eyebrow (2), over mastoid (2) and clavicle (1). Gather baseline EEG (by pressing the impedance button and print EEG). Set ECT machine to correct dose (see treatment protocol). Patient is anaesthetized and muscle relaxant is administered. Bite-block is put in place to protect dentition. Treatment delivery Apply ECT electrodes as per treatment protocol. Test static impedance. Ask the ECT nurse to Check impedance. Static impedance must be under 3000 ohms to deliver treatment. The nurse will press the impedance button and verify impedance or advise if electrode contact needs to be adjusted. ECT doctor clearly issues verbal instruction to treat e.g. Treat at 75%. ECT nurse repeats the instruction Treating at 75% and presses Treat button. (The stimulus lasts 1-6 seconds depending on dose). Time the visible convulsion with digital stopwatch. Observe EEG and stop tracing when EEG activity is back to baseline. If no seizure - repeat the process at the next level on the stimulus dosing schedule. Confirm with anaesthetist that patient is stable before further stimulus is delivered (A maximum of three stimulations providing the patient is stable). When the treatment is complete, remove EEG electrodes. Remain available to assist anaesthetist if required. Record details of the treatment on the ECT record form and patients notes, noting any recommendations for next treatment. Version 3 (January 2012) Page 30

31 Interpreting EEG recordings Recording Baseline Stimulus Preictal Epileptic Early polyspike (anaesthesia effect) recruiting (Tonic) seconds 2 5 (Rough estimates) Late Polyspike and Termination Immediate Poly-spike slow-wave (Clonic) postictal min 0-5 min 0-10 min 5-20 min Postictal postictal postictal postictal Fig 1 Schematic of various phases of a typical ECT seizure. Version 3 (January 2012) Page 31

32 Source: Weiner RD, Coffey CE, Krystal AD: The monitoring and management of electrically induced seizures. Psychiatric Clan North Am 14: , Ictal EEG The above figure illustrates the typical ictal and postictal EEG phases that may be observed during the ECT treatment. Baseline The baseline pre-stimulus EEG may be noticeably different from the patient s baseline waking EEG because of the anaesthetic administered. Such preictal baseline recordings often consist of mixed fast and slow activity that may be higher in amplitude than that observed during the waking state. This effect usually varies with how deeply the patient is anaesthetised at the time the physician is ready to deliver the stimulus. Electrical stimulation During the period of electrical stimulation, EEG activity is blocked because of interference by the stimulus current. ECT devices generally only begin recording after the stimulus has been administered. Preictal activity After the electrical stimulus, a brief preictal period of low amplitude fast activity can sometimes be seen. Epileptic recruiting rhythm The preictal activity may be followed by a brief period of very rhythmic activity of low to moderate amplitude in the alpha or beta range known as the epileptic recruiting rhythm. This phenomenon is believed to be associated with the synchronizing effects of thalamocortical projections during the early stages of seizure generalisation. Both the preictal and the epileptic-recruiting-rhythm phases are frequently absent. Polyspike activity Often the earliest phase of the seizure noted is that characterised by high frequency polyspike activity. This phase is concurrent with the tonic and early clonic components of the motor response and usually lasts approximately seconds. In some patients, polyspike activity is never present, and relatively rhythmic slow-wave activity in the theta and delta range can be observed throughout the period of motor tonus. The significance of this variation is unclear. Version 3 (January 2012) Page 32

33 Polyspike and slow wave complexes During the clonic phase of the ictal motor response, the polyspike activity evolves into repetitive polyspike and slow-wave complexes, which are synchronous with the clonic movements. Termination phase A termination phase of the seizure may be observed, in which the amplitude and the regularity of the polyspike and slow-wave pattern gradually diminish. Alternatively, the polyspike and the slow-wave phase may end abruptly. Postictal phase The postictal phase begins immediately upon EEG seizure termination and the EEG usually appears flat. It is prudent to allow the flat baseline for seconds to detect any spontaneous re-emergence of seizure activity. Version 3 (January 2012) Page 33

34 Monitoring response to treatment Version 3 (January 2012) Page 34

35 The course of treatment ECT is not a single treatment. It is usually administered twice weekly up to an average duration of 6 treatments. Patients vary greatly in the number of treatments they will require and it is advised that their mental state and prescription be reviewed after each treatment and absolutely must be reviewed once weekly. No more than 2 ECT treatments may be prescribed at any one time. Mode of Improvement The commonest mode of improvement with ECT is an immediate response followed by a degree of relapse. After perhaps the first or second treatment, the patient may be better that day or the following day but then worsen again. This is an encouraging sign and suggests that the treatment is going to be effective. After each subsequent treatment, the response is greater and persists for longer. People with significant lack of motivation may find that motivation returns before mood lifts. This can cause a period of agitation following ECT, during which risk of self-harm may increase. Clinicians are advised to be wary of this. Note: The first treatment is always a dose finding exercise and will be unlikely to produce clinical benefit. The patient should be made aware of this. When to stop? ECT should be continued until the patient has regained full health or until there is a lack of further improvement. These judgments will be made by the patient s own clinical team. There is no evidence that giving further ECT after full recovery is effective. Effectiveness of ECT For depressive illness, ECT has shown to be effective in more than 70% of cases. Lesser degrees of response occur in a significant proportion of the remainder. Some patients do not respond and only a very small minority shows any worsening of symptoms. Patients who do not respond to ECT can be tried on other medications or combinations of medication. Prevention of relapse ECT provides a rapid and short term improvement in severe symptoms. It is therefore important that patients who respond to ECT should have prophylactic antidepressant treatment to prevent relapse. This may take the form of antidepressant drugs, or mood stabilising drugs such as Lithium, Carbamazepine or Sodium Valproate. However, some people who respond well to ECT fail to remain well on any of the above treatments. Version 3 (January 2012) Page 35

36 Maintenance ECT NICE does not recommend the use of maintenance ECT. However, there may be patients who respond to nothing else. Patients who are considering maintenance ECT should be made aware of the NICE recommendations in discussions about their treatment. NICE guidance on the use of ECT NICE guidelines suggest that ECT is only used to achieve rapid and short term improvement of severe symptoms after failure of an adequate trial of other treatments and/or potentially life-threatening illness, that it is only used in severe depressive illness, prolonged or severe mania and catatonia. NICE do not recommend ECT for maintenance treatment or for schizophrenia. The decision to give ECT should be based on documented risks and benefits, including cognitive impairment and risk associated with no treatment. They have advised that there are some situations where special care should be taken for example with the very young or the very old. Furthermore all patients having ECT should have documented valid consent involving their carer if possible. Advanced directives and carer issues should be taken into account if consent is not possible. During the course of ECT the clinical status should be monitored after each treatment and stopped if response is achieved or there is evidence of adverse effects. Cognitive functions should be measured preferably after each ECT treatment and at a minimum at the end of the treatment course. Repeat ECT is only used if the criteria for use are met, that is, if there was a previous good response to ECT or if they had not previously responded, all other options had been considered and there has been full consultation with the patient and his representatives. Version 3 (January 2012) Page 36